DESCRIPTION: The overall aim of this proposal is to examine the impact of work environment on patient quality of health care in a large integrated health system. The proposal incorporates three linked aims sharing common data sources and study populations. Findings from the nursing unit level and individual worker level analyses in the first two study aims will be incorporated into the interventions tested in the final study aim. Findings from these linked projects will be used to understand and improve quality of patient care and work environment in hospital settings. In Aim 1, we will prospectively evaluate the relationship between working environment and quality of health care in a large health care system, at the nursing unit level of measurement. Measures of staffing, delivery of care model, employee satisfaction, and employee perception of safety will be used to predict patient outcomes including adverse events, patient satisfaction, and patient perception of safety. We will obtain these measures for almost 6000 patient discharges, aggregated at the level of more than 80 nursing units in 13 hospitals. In Aim 2, we will examine the effects of working conditions as proximal triggers or precipitants of medical errors at the individual worker level of measurement using a case-crossover design. We will interview 300 nursing personnel who have made an identified "near miss" error to examine how the risk of making a medical error is changed by such factors as duration and timing of work shifts, fatigue, sleep disruption, unfamiliar work location or work tasks, and work pace. In Aim 3 we will examine the impact of changes in work organization and working conditions on quality of care, using a Human Factors Engineering approach. We will analyze work processes on four inpatient medical units using task analysis, link analysis, and usability analysis. This will allow a more in-depth evaluation of working conditions than the wider-scale study in Aim 1. In conjunction with unit-based practice committees, we will design, implement, and test changes in targeted work processes to improve efficiency and quality of care. Measurement of changes in quality of care following the intervention will include those used in Aim 1 as well as specific processes of care measures.